Xhance — Blue Cross Blue Shield of Alabama

other FDA labeled indications for Xhance

Initial criteria

ONE of the following: • The patient has a diagnosis of chronic rhinosinusitis with nasal polyps (CRSwNP) OR • The patient has a diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) OR • The patient has another FDA labeled indication for the requested agent and route of administration OR • The patient has another indication that is supported in compendia for the requested agent and route of administration
AND if the patient has an FDA labeled indication, then ONE of the following: • The patient’s age is within FDA labeling for the requested indication for the requested agent OR • There is support for using the requested agent for the patient’s age for the requested indication
AND ONE of the following: • The patient has tried and had an inadequate response after 90 days of therapy with ONE generic OR OTC intranasal corticosteroid OR • The patient has an intolerance or hypersensitivity to therapy with ONE generic or OTC intranasal corticosteroids that is not expected to occur with the requested agent OR • The patient has an FDA labeled contraindication to ALL generic AND OTC intranasal corticosteroids that is not expected to occur with the requested agent
AND the patient does NOT have any FDA labeled contraindications to the requested agent

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND • The patient has had clinical benefit with the requested agent AND • The patient does NOT have any FDA labeled contraindications to the requested agent

12 months